Child Health Service – First Registration Form (1) This form consists of two pages (Please read through the “Collection of Personal Data - Statement of Purposes” before you fill in this registration form and return the completed form to registration counter on the day of your first appointment.)

Name in Chinese:

Name in English:

Particulars of Child

Surname Given Name

Surname Given Name

Sex: Male Female

Date of Birth (dd-mm-yyyy):

Place of Birth: Hong Kong Mainland China Others (Please specify)

Date of entry if born in Mainland China (dd-mm-yyyy):

Name of Birthing Hospital in Hong Kong:

Registration No. of Birth Certificate (if not available, other documents#):

Address^:

Flat Floor Block

Name of Building Estate

Street No. Street Name District

(Home)

(Mother’s Mobile) (Mother’s office)

(Father’s Mobile) (Father’s Office)

Email:

(Note: the provided email address will be used solely for communication by Department of Health) Other than parents, please provide contact information of another person.

Name: Relationship: Tel. No.:

Label

- - Time of Birth (24-hr clock):

- -

Tel. No. :

＠ (This email belongs to: Mother Father Other Carers)

Primary Contact: Mother Father Other

Particulars of Mother

Name in Chinese: Surname CCC(1): Surname

Given Name Given Name

Name in English: Surname Given Name

Date of Birth (dd-mm-yyyy): - -

HKID / Other Document No.:

Entry Type: 0) Permanent Resident(2)

1) Non-Permanent Resident from Mainland China(2)

5) Visitor from Mainland China (Exit-entry permit / Recognizance)

6) Non-Permanent Resident from places other than Mainland China (2)

7) Visitor from places other than Mainland China

9) Others (please specify)

Occupation:

Education Attainment: 1) No Schooling

2) Pre-primary (Kindergarten / child care centre)

3) Primary (P1-P6)

4) Lower Secondary (S1-S3)

5) Upper Secondary (S4-S5/6/7, Project Yi Jin)

7) Post-secondary (Diploma / Certificate / Sub-degree course)

8) Post-secondary (Degree / Postgraduate course)

P) Others:

Particulars of Father

Name in Chinese: Surname CCC(1): Surname

Given Name Given Name

Name in English: Surname Given Name

Date of Birth (dd-mm-yyyy): - -

HKID / Other Document No.:

Entry Type: 0) Permanent Resident(2)

1) Non-Permanent Resident from Mainland China(2)

5) Visitor from Mainland China (Exit-entry permit / Recognizance)

6) Non-Permanent Resident from places other than Mainland China (2)

7) Visitor from places other than Mainland China

9) Others (please specify)

Occupation:

Education Attainment: 1) No Schooling

2) Pre-primary (Kindergarten / child care centre)

3) Primary (P1-P6)

4) Lower Secondary (S1-S3)

5) Upper Secondary (S4-S5/6/7, Project Yi Jin)

7) Post-secondary (Diploma / Certificate / Sub-degree course)

8) Post-secondary (Degree / Postgraduate course)

P) Others:

FHS 11A (rev Oct 2019) Please continue on Page 2

Contact Information

Parents’ Marital Status: Never Married Married Widowed Divorced

Separated Cohabited Comprehensive Social Security Assistance Recipient: Yes No Number of Children:

Expected Date of Confinement (EDC) (dd-mm-yyyy): Weight at Birth (kg): Type of Birth:

Single Twin Multiple

(only applicable to services of Immunisation, Developmental Surveillance, Hearing Screening, Preschool Vision Screening,

Child Health Service – First Registration Form (2)

- -(e.g.: X.XXX, to the third decimal place)

Articulation Assessment & Developmental Assessment)

Others: I agree to receive SMS Reminder through HK mobile tel. no. of the following person: (Select ONE): Mother Father

I do not agree to receive SMS Reminder for appointments

Family Health Service “Online Membership Program” Registration Do you agree to become a member of the Online Membership Program, and receive the latest information on parenting and child health? Please on the appropriate box. Yes No

If you agree, we will send the “Parent-Child e-Link” e-newsletters to your email address provided in this registration form. Please choose the language of the e-newsletters:

Completed by Chinese (Traditional) Chinese (Simplified) English

I understand and accept that the information provided above will be used by the Department of Health in accordance with the “Collection of Personal Data - Statement of Purposes”. Signature: Name: Relationship: Mother Father Others (please specify)

HKID Others (please specify): Document No. (First 4 alphanumeric characters):

For others, ID document held:

Date:

(Please show the above document (original or copy) for verification.)

Remarks: (1) CCC (Chinese Commercial Code): refers to 4-digit code below the name in the Hong Kong Identity Card (see diagram below)

Chinese Commercial Code (if any)

Types of Identity Card

(2) Permanent Resident refers to person who holds the Hong Kong Permanent Identity Card.Non-Permanent Resident refers to person who holds the Hong Kong Identity Card.Please refer to the types of Hong Kong Identity Cards (see diagram above)

# Parents or guardians should provide a valid Hong Kong birth identity document once it is available. If fail to do so, all child health services will be charged as per the prevailing gazetted charges for Non-Eligible Persons.

FHS 11A (rev Oct 2019)

Other Family Particulars

SMS Reminder for appointments

Other Information of Child

^ If Hong Kong address is not provided, we will not be able to send letters to you.

SMS Language (Select ONE): Chinese (Traditional) Chinese (Simplified) English Remark: The SMS Reminder Service will be effective within 14 days after submission of this Form. DH cannot guarantee successful receipt of SMS message.

Mobile tel. no.: